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2013All "ff a Parking Lot bL w�id c�,,�L�s ( zhi�> situ (u.t( a • .S >1 CL 0 E CD wL 1 � March 8, 2013 Bellino Fireworks, Inc. 501 Olson Drive, Suite 210 Papillion, NE 68046 RE: Firework License in Blair Dear Ms. Bellino, The Teammates of Blair has been awarded one (1) license for fireworks in Blair for 2013. We have received your Certificate of Insurance and Nebraska State Fireworks Permit License for 2013. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be sized accordingly to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size). You are also required to furnish trash service providing a trash container no larger than six (6) yards to handle your own trash accumulation (see attached map for trash storage). All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, apa-A Brenda Wheeler City Clerk Cc: Teammates of Blair, PO Box 264, Blair, NE 68008 eawl.N000UIa OPPOflTUNITY 218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 ® Fax 402 -426 -4195 ® E -mail clfyofblair @ci.blalr,ne,us —an 0 Q I • 1. Calendar Year for Application 2013 2. Name of Applicant MEpm n F F) L.A► wk 3. Address of Applicant pC, a�& 26 & Avg I 14 L'8®°8 Contact Person Ma p i 4 � a o u o c- i Phone # A42 ,6,- n. c a 2 4. Is applicant working through a vendor? Yes LJ No ❑ 5. Name of vendor participating with applicant (if applicable) 9r= hj 6. Address of vendor o Sow ; j j F_ S u g r E b o o PAPILLintIJ t , WE 69,041 Contact Person Vag E p, r Phone # fg oz> 9 - 35- i q i 6 Is certificate of insurance held b a ❑ 7. y applicant or vendor? Vendor [2/ Applicant 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes No ❑ 9. License fee - $5,000 (Attached) 10. Certificate -of Insurance {Attached) 11. Sales Tax # &1i4it4 (Name of Holder) F3 E _-L_ j _ j ,4,n r, aENI i01a KS .; i gn Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for. a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this applioat on_and_the -sale-- and_storage ot__firevv_o— --in the _C tv of Blair, Nebraska. a Applicant } Vendor (if applicable) Dat ® - 4 Date FOR CITY USE ONLY: j Date Received Time Received Applicant awarded license: Yes ❑ _No- NEBRASKA STATE FIRE MARSHAL 246 South 14th Street Lincoln, NE 68508-1804 LICENSE FOR SALE OF FIREWORKS Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 91:59 PM July 4 OR 12:01 AM December 29 and ending 11:59 PM December 31 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. ART flifflUMMA This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: February 22, 2013 02:20 PM TYPE OF LICENSE AND FEE: Retail Permit (July) - $25.00 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Vets Field (13th and Butler) Blair Tent in parking lot DISTRIBUTORS) /JOBBER(S): Bellino Fireworks (2013 -RP- 4222472 -6) SALES TAX NUMBER: 8341141 Teammates of Blair COUNTY: Washington DATE ISSUED: February 07, 2013 03:02 PM STATE FIRE MARSHAL LICENSE NUMBER: 2013 -RP- 4442254 -38 -01 AC CERT L DATE (MM /DD/YYYY) 2/5/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Britton Gallagher One Cleveland Center, Floor 30 1375 East 9th Street CO TACT NAME: PHONE FAX Ext :216- 658 -7100 A/c No):216-658-71 01 E -MAIL ADDRESS: INSURER (S) AFFORDING COVERAGE NAIC # Cleveland OH 44114 INSURER A:L xin on Insurance Co /4/2013 /4/2014 INSURED INSURER B: INSURER C: Bellino Fireworks Inc 501 Olson Drive, St 210 Papillion NE 68046 INSURER D: DAMAGE TO RENTED PREMISES Ea occurrence $50,000 INSURER E: $ INSURER F: CLAIMS -MADE a OCCUR COVERAGES CERTIFICATE NUMBER: 874952064 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY ) POLICY EXP (MM/DD/YYYYI LIMITS A GENERAL LIABILITY 379100 -05 /4/2013 /4/2014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $ CLAIMS -MADE a OCCUR PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000 POLICY PRO- X LOC $ AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA T RY LIMITS I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Location: 1301 Butler St. (Vets Field) Blair, NE BC Prairie Park Add Lot 4 -11 E. 92ft. of Lot 3 Blk 4 Additional insured: City of Blair, NE Teammates of Blair Bellino Fireworks, Inc. Donald J. and Valerie R. Bellino %..cR i irwH i c nULUCrc GANGtLLA I IUN Bellino Fireworks, Inc. 501 Olson Drive Suite 210 Papillion NE 68046 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD A' 1 1 MIFYI 1: Calendar Year for Application 2013 2. Name of A Jc, s e "s c" N Applicant �; + �"` ®� 3. Address of Applicant J7 17 car /V Co Contact Person c► r Phone # - 42-&-044 4. Is applicant worldng through a vendor? Yes No El 5. Name of vendor participating with applicant (if applicable) h w r S, u S. If held by vendor, does insurance name applicant and city as additional insurers? Yes A No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # t -woo m, (Name of Holder) ,, ► ire,.,, O V Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this application and the sale and storage of fireworks in the City of Blair, Nebraska. Vend&f<f applicable) Date Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes 11 No El DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 230539 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. P.m, Mimi.. POLICY TERM COVERAGE LEM OF LIAB ILITY INSURED OPERATIONS Admiral Insurance Company POLICY NO. CA000003209 -22 -1091 Wild Willy's Fireworks 791.3 Hidden Valley Drive Papillion, NE 68046 March 1, 2012 to March 1, 2013; Both Days 12:01 A.M. Standard Time Premises- Operations Liability: ® Occurrence Basis ❑ Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. The sale of consumer fireworks (1.4G) and related products at the insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the insured location and/or 4) an entity for which coverage is required by written contract. NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South 16' Street Blair, Nebraska 68008 Voice (402) 4264191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 ADDRESS OF INSURED LOCATION Veterans Memorial Ball Field Blair, NE 68008 PERIOD OF OPERATION June 23 2013 — July 6 d `, 2013 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. February 25' ` 2013 DATE OF ISSUE AJ. STRINGER, PRESIDE DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 ria - Difird"11"FN "Al aml 1`111 111111111 . - No. 250138 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -22 -1091 NAMED INSURED Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 POLICY TERM March 1, 2012 to March 1, 2013; Both Days 12:01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ❑ Claims Made Basis LIMIT OF LIABILITY $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and/or 4) an entity for which coverage is required by written contract NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 4264191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. v February 25 "; 2013 DATE OF ISSUE A. GER, PRESIDENT CITY OF BL AIR APPLICATION FOR FIREWORK LICENSE 1 Calendar Year for Application 2013 �I � i � � �� � 2. Name of Applicant r 0-krAd 3, Address of Applicant 66x�V2 Contact Person L I lexe 8 --- Phone4- 4, Is applicant working through a vendor? Yes N-O . Tae of vend or tici ating with apAicant (ff applicable) W 1 b-(- 6. Address ofvendor S. L1J%Jj,,-cbQ 5 q Contact Person Lo'lCe Phone # 2. 3 - 2,12's 7. Is certificate- of insurance held by applicant or vendor? Vendor A- Applicant El 8. If held by vendor, does insurance name applicant and city as additional insurers? N - Yes A No Lioense fee - $5,000 (Attached) 10, Certificate of Insurance (Attablied) It. Sales Tax 4 Qo j- g>xo I I qjj_q, (Name of Holder) C- I/we, the authorized representative of the above, applicant and/or vendor, do hereby inake, application for a fire,works license to be issued by and through the City of Blair, Nebraska. Uwe fluther agree to abide by all re ordinances ofAie City of'Blah-, Nebraska and State of Nebraska relative to this /1 and V sale and stor#( applicati i 94ofX1reworks in the City of Blair, Webraska, FOR CITY USE ONLY� Date Received Time Received Applicant awarded license: Yes 0 No 0 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALAB AMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 250139 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -22 -1091 NAMED INSURED Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 POLICY TERM March 1, 2012 to March 1, 2013; Both Days 12:01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ❑ Claims Made Basis LEVM OF LIABILITY $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and/or 4) an entity for which coverage is required by written contract. NAMES) OF ADDITIONAL INSURED(S) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 4264191 Fraternal Order of Eagles #3215 PO Box 242 Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. February 25 , 2013 DATE OF ISSUE A. GER, PRESIDENT DRA YTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 230540 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER NAMED INSURED POLICY TERM COVERAGE LIMIT OF LIABILITY INSURED OPERATIONS Admiral Insurance Company POLICY NO. CA000003209 -22 -1091 Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 March 1, 2012 to March 1, 2013; Both Days 12:01 A.M. Standard Time Premises - Operations Liability: ® Occurrence Basis ❑ Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. The sale of consumer fireworks (1.4G) and related products at the insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the insured location and/or 4) an entity for which coverage is required by written contract. NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 4264191 Fraternal Order of Eagles #3215 PO Box 242 Blair, NE 68008 ADDRESS OF INSURED LOCATION Veterans Memorial Ball Field Blair, NE 68008 PERIOD OF OPERATION June 23 2013 — July 5 d ', 2013 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. February 25 d ', 2013 DATE OF ISSUE . STRINGER, PRESIDE DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 r , r No. 321109 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER NAMED INSURED POLICY TERM COVERAGE LIMIT OF LIABILITY Admiral Insurance Company POLICY NO. CA000003209 -23 -1091 Wild Willy's Fireworks, LLC 17105 S. Hwy 50 Springfield, NE 68059 March 1, 2013 to March 1, 2014; Both Days 12:01 A.M. Standard Time Premises - Operations Liability: ® Occurrence Basis ® Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The sale of consumer fireworks (1.4G) and related products at the Insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the Insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the operation of the Insured location and/or 4) an entity for which the Named Insured is required by written contract to provide coverage. NAMES) OF ADDITIONAL INSUREDS) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 426 -4191 Fraternal Order of Eagles #3215 Blair, NE 68008 ADDRESS OF INSURED LOCATION Veterans Memorial Ball Field Blair, NE 68008 PERIOD OF OPERATION June 24 2013 — July 5 2013 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. March 20 2013 DATE OF ISSUE A . �NGER� R ESIDE DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 NO. 340809 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -23 -1091 NAMED INSURED Wild Willy's Fireworks, LLC 17105 S. Hwy 50 Springfield, NE 68059 POLICY TERM March 1, 2013 to March 1, 2014; Both Days 12:01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ® Claims Made Basis LIMIT OF LIABILITY $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and /or 4) an entity for which the Named Insured is required by written contract to provide coverage. NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South W' Street Blair, Nebraska 68008 Voice (402) 426 -4191 Fraternal Order of Eagles #3215 Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. March 20 2013 DATE OF ISSUE A.. STRINGER, PRESIDE DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 CER'T'IFICA'T'E OF INSURANCE NO. 340808 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -23 -1091 NAMED INSURED Wild Willy's Fireworks, LLC 17105 S. Hwy 50 Springfield, NE 68059 POLICY TERM March 1, 2013 to March 1, 2014; Both Days 12 :01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ❑ Claims Made Basis LIMIT OF LIABILITY $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and/or 4) an entity for which the Named Insured is required by written contract to provide coverage. NAMES) OF ADDITIONAL INSURED(S) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 426 -4191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and /or the undersigned. DRAYTON INSURANCE BROKERS, INC. March 20 2013 DATE OF ISSUE A.. STRINGER, PRESIDE DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 NO. 321108 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -23 -1091 NAMED INSURED Wild Willy's Fireworks, LLC 17105 S. Hwy 50 Springfield, NE 68059 POLICY TERM March 1, 2013 to March 1, 2014; Both Days 12:01 A.M. Standard Time COVERAGE Premises- Operations Liability: ® Occurrence Basis ❑ Claims Made Basis LIMIT OF LIABILITY $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The sale of consumer fireworks (1.4G) and related products at the Insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the Insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the operation of the Insured location and/or 4) an entity for which the Named Insured is required by written contract to provide coverage. NAME(S) OF ADDITIONAL INSUREDS) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 426 -4191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 ADDRESS OF INSURED LOCATION Veterans Memorial Ball Field Blair, NE 68008 PERIOD OF OPERATION June 24 2013 —July 5 2013 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and /or the undersigned. DRAYTON INSURANCE BROIERS, INC. March 20 2013 , DATE OF ISSUE A . TRINGER, PRESIDE NEBRASKA STATE FIRE MARSHA South Lincoln, NE 68508-1804 LICENSE FOR SALE OF FIREWORKS Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 OR 12:01 AM December 29 and ending 11:59 PM December 31 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. I FA This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: April 09, 2013 10:34 AM TYPE OF LICENSE AND FEE: Retail Permit (July) - $25.00 1301 Butler Street COUNTY: Blair Washington Tent in parking lot DISTRI UTOR(S) /JO R(S): Wild Willys Fireworks (2013 -RP- 4230236 -7) SALES TAX NUMBER: DT ISSU : 001 - 010138714 March 26, 2013 03:25 PM STATE FIRE MARSHAL Josephs Coat and Thrift Store LICENSE NUM 2013 -RP- 4769836- 125 -01